Health promotion in radiographic practice

RAD RAPHERS

Radiography(1996) 4, 9-16

ORIGINAL ARTICLES

Health promotion in radiographic practice

Alan Castle and Jo-Ann Reeves

Cerrtre for Rndiograplly Education. University oJ Porkmouth, St Marys

Hospital, Portsmoutl~ PO3 6AD, U.K. (Received I1 October 1996; accepted 20

September 19%)

Keywords: disease prevention; health protection; health education.

Purpose: To discover what opportunities are available for radiographers to develop and implement health promotion activities in their professional practice. Methods: A workshop was conducted at the 10th International Society of Radiographers and Radiological Technologists Teachers Seminar held at the University of Nottingham, United Kingdom from 28 July to 2 August 1996. A total of 39 delegates from over 15 countries attended the 3 h workshop to consider the role of health promotion in radiographic practice. Results: There was a strong belief that health promotion activities should be the responsibility of all health professionals, and that special training is required if effective strategies are to be adopted. Participants were positive about the relevance and potential opportunities for health promotion activities in radiographic practice, and many examples of potential opportunities within the context of disease prevention, health protection and health education were highlighted. Conclwions: The benefits of radiographers adopting a health promotion strategy in radiographic practice is that whilst they will retain their specialist skills they will also have a wider, more generalist, role in developing the health of the nation.

Introduction

Health, education, health education and health promotion are broad, and often confusing, concepts. Attempts to define health encounter a number of problems. Individuals find it difficult to articulate what it is like to be healthy, and often find it much easier to say what it is .like to be unhealthy. For example, researchers have identified social class differences in the concepts of health, with middle-class respondents having a more positive view than those in the working-class [I, 21.

It has been suggested that it is impossible to think about health without thinking about disease, and thus it is easier to specify departures from the norm of health than it is to specify the norm itself. Blaxter suggests that men have a more positive notion of health as being fit, whilst women have a more negative notion of health as not being ill 121.

1076-6174/96/010009+06 $16.00

Whether health is considered simply as not being ill or more of a state of general well-being, can be summarized in the two main theories of health. The medical view equates health with normality or the absence of disease, illness and injury. The body is seen as a machine with separate parts, and being healthy means that all the parts function correctly, whereas being ill .equates to some malfunction. Medical treatment aims to restore normal functioning or health [3]. The holistic view, on the other hand, is multi-dimensional and takes account of physical, mental and social well-being and not merely the absence of disease or infirmity [4]. Included in this holistic view is the humanist approach which sees different states of health for each individual [5]. For example, a cancer sufferer clearly experiences ill-health, although they can also attain a state of well-being and set achievable health goals.

0 1996 The College of Radiographers

10 Castle & Reeves

The nature and goals of education, unlike health, have been debated since the time of the ancient Greeks. Training is closest to the idea of indoctrination involving imparting a single set of ideas. True education provides relevant information and appropriate skills within a sub- ject area, and also encourages a questioning attitude and a cultivation of the abilit$ to make choices [6].

The concept of.health education, until the 198Os, was widely used in the context of giving individuals information and working towards changing attitudes and behaviour to health. The aim was to enhance positive health and prevent or diminish ill-health [a, 71. This approach was designed to enable individuals to acquire appropriate information;apply good health practices, access preventive services, use medication correctly and recognise early symptoms of disease.

Since then health promotion has become more common as an umbrella term for a range of activities which include health education. Promo- tion in the health context (means) improving health: advancing, supporting, encouraging and placing it higher on personal and public agendas [4, p. 191. Whilst there may be a philosophical distinction between health education and health promotion, in practice they overlap one another, and many health professionals are strongly com- mitted to health education and the promotion of health [a]. Thus health promotion is a sphere of activity which encompasses diseases prevention (e.g. imrnunisation and cervical screening), health protection (e.g. water fluoridation and no- smoking policies) and health education (e.g. raising awareness and influencing life-styles).

This paper is a report of a workshop conducted by the authors at the 10th International Society of Radiographers and Radiological Technologists Teachers Seminar held at the University of Nottingham, United Kingdom from 28 July to 2 August 1996. The theme of the seminar was Educational Needs of Students: Preparing Students for Entry into Todays Health Care Systems, and the workshop was devised to enable participants to consider the possible strategies for health promotion in radiographic practice. A total of 39 delegates from over 15 countries attended the 3 h workshop.

The aims of the workshop were for participants to: 1 consider who has responsibility for health promotion activity;

2 identify individuals or groups who should be targeted by health promotion activities; 3 ascertain approaches to health promotion which would be most effective; 4 identify opportunities for disease prevention, health protection and health promotion in radiographic practice.

Methods

The term workshop has many different meanings, but is generally considered as a structured set of activities which provide opportunities for learning through thinking and discussion [9]. The advan- tages of small groups is that participants can learn from each other, develop a sense of community and cooperate to stimulate and provide a greater variety of solutions [lo]. At the end of a workshop it is important to provide an opportunity for participants to evaluate activities, as the absence of any evaluation may leave people unable to voice their views about content and delivery [II]. The workshop consisted of group and individual activities. Activities 1 and 2 were both scheduled for approximately 50 min, with participants forming five groups to discuss the issues raised and to report back at a plenary session after 30 min. Activity 3 involved individual completion of an action plan and evaluation form.

Activity 1

The workshop began with a 30 min introduction and discussion of the concepts of health, education, health education and health promotion. This was followed by an explanation and distribution of three grids relating to the first three aims of the workshop. Each grid was divided into four para- digms generated from two dimensions (these are displayed graphically in Figs 1 to 3).

The first grid was designed to ascertain whether participants saw health promotion activity as part of their professional remit, and whether special training is required for those attempting to promote health in their professional practice.

The second grid was concerned with establish- ing whether the focus of health promotion would be best aimed at individuals or particular groups. This second grid also considered whether health promoters should focus their activities on educating individuals or on educating the educators who

Health Promotion 11

might go on to develop strategies for health promotion through their curricular activities.

The third grid considered whether health promotion should be authoritative (top-down and expert-led) or negotiated (bottom-up and valuing individual autonomy). It also considered whether direct approaches (e.g. legislative action and individual persuasion) or indirect approaches (e.g. educational curricula and television soap operas) would be more effective.

At the end of this activity participants were asked to place a mark best reflecting their position on each grid. The completed grids were combined to give an overall summary of the responses of all of the participants.

Activity 2

This began with a brief review of Tannahills model of the three components of health promotion: disease prevention, health protection and health education [12]. This model of health promotion is widely accepted by health professionals, although where the activities of one component begin and another end generally cause some disagreement. Participants were again invited to form the same five groups and consider what opportunities are available for disease prevention, health protection and health education in radiographic practice. All responses to each of the three elements of health promotion were collected, and issues arising from the feedback discussed.

Activity 3

After a summary of the issues and common criticisms within health promotion, participants were asked to complete an action plan and an evaluation form before the workshop was concluded.

The purpose of the action plan was for each participant to consider, individually and confiden- tially, one aspect of health promotion they would undertake, and one health promotion activity they would investigate and introduce into their practice, as a result of attending the workshop. Gaine recommends the use of an action plan as a closing activity to highlight the need to consider issues discussed in the context of action and change within the workplace [KS].

The purpose of the evaluation form was twofold: it provided participants with a structured way of

Special training required

* * * ** * *

* * h * * *8 * *

* :x * & *

All health professionals

I 5 -

Non-health professionals

No special training required

Figure I. Who is responsible for health promotion activity? (n=39)

reviewing and reflecting on the workshop and it allowed the collection of information for the authors regarding the effectiveness of their efforts.

Results

Activity 1

Figure I summarizes the responses to the question concerning the responsibility for health promotion activity. The distribution of responses indicates that the majority of participants (51%) considered that health promotion is the responsibility of all health professionals and that special training is required. Thirteen responses were on the borderline indicating that they thought health promotion the responsibility of all professional groups who come into contact with members of the general public such as teachers, social workers and community leaders. Three responses considered more emphati- cally that all professionals should be involved. All participants considered that special training for health promotion activities is essential.

Figure 2 represents the views of participants regarding the targeting of health promotion activities. There was more diversity of opinion here, although a majority (67%) suggested that everyone, rather than particular groups, should, be involved. Approximately 50% of participants thought that educating individuals. was the best approach, whilst the other 50% considered that educating educators is more effective and efficient.

Figure 3 illustrates the responses of participants in terms of the most effective approaches to health promotion. The majority of participants (77%) considered that a negotiated, rather than an authoritarian, approach to health promotion.,is the

12 Castle & Reeves

Particular groups

I * I * *

* 02 I

Educatin f

* * 4: * individua s *-*

Educating * * educators

* * *

* * * * ** ** I* ** I *

Eve&one

Figure 2. Which individuals or groups should be targeted? (n=39)

Direct I w=l=m *** . 0

* 1 * *g** *

* Authoritarian * L/ *

* * Neg*otiaied

* j;i * **

* * x *

Indirect * *

Figure 3. What approach to health promotion is most effective? (n=39)

most appropriate style. In terms of method 67% favoured a direct approach, whilst 33% preferred an indirect approach.

Activity 2

The second activity in the workshop was concerned with participants identifying what opportunities they considered to be available for disease prevention, health protection and health education in radiographic practice. It was agreed, and accepted, that there was a considerable amount of overlap of the three components of health promotion, and Tables 1 to 3 identify potential opportunities suggested by participants.

These tables indicate that participants believe there is potential for the development of health promotion activities for their own health as well as that of their colleagues, members of the public and patients with whom they have daily contact.

Activity 3

Since the action plan was completed on an individual and confidential basis, no results were sought or

obtained. However, the results of the evaluation form are shown in Table 4. Each of the seven statements invited participants to tick one of the responses which ranged from YES! (very positive) to NO! (very negative). The numbers in each box refer to the totals obtained for each of the options offered.

These results indicate a positive response to both the content and delivery of the workshop. In terms of content 85% (n=33) of participants reported that they could see the relevance of health promotion to their professional practice, and 77% (11.=30) indicated that th ey would investigate further opportunities for health promotion activities. In terms of delivery, 85% (12~33) enjoyed the way.in which the workshop was presented, and a similar number (1z=32) found the workshop worth at tending.

The evaluation form also invited participanb to offer any other comments they had about the workshop in general. Positive comments included: well done, thought provoking exercise, very reflec- tive, thank you very much, a difficult session well managed and lots of food for thought. Other more extensive comments were:

Very pertinent issues which I see as vital to include in undergraduate education in order to increase graduates awareness of health promotion issues.

As health professionals we had very little idea about health.

This was a challenging task, due to the varied background and culture of participants. Our reali ties can be quite different and present us with varied problems and situations.

This has helped me see that I can participate in health promotion.

Some negative comments were received in terms of: it went too fast, too little time to reflect, language problems and cultural content of group not totally accounted for in design and data related to the session.

Discussion

Activity 1

It was gratifying to find that participants generally considered that all health professionals had a role to play in health promotion, and acknowledged that it was a skill that required some training. So often the view is taken by radiographers that their

Health Promotion 13

Table 1. Disease prevention opportunities

Education for patients and staff about radiation protection.

Involvement in the development of protocols for the more effective use of non-ionizing radiation imaging modalities.

Education about, and implementation of, appropriate health and safety regulations (e.g. lifting and toxic fumes).

Adherence to protocols to minimize the spread of infection.

The need for health professionals to adopt a healthy lifestyle (e.g. appropriate diet, exercise, stress relief) i.e. become good role model.

Adopt good professional practices to avoid injury/illness to self and patients.

Development of screening programmes (e.g. mammography, screening for osteoporosis).

Wider use of ultrasound in pregnancy to ascertain status of fetus and mother so that the possibility of abortion can be considered.

Looking for opportunities to give information to patients (e.g. minimize risk of skin cancer, encourage the use of immunization programmes).

Table 2. Health protection opportunities

Lobbying for, and the development and implementation of, legislation and regulations for safe practice.

Taking responsibility for professional practice (e.g. application of ALARA principles of radiation protection and safeguarding patients who may be pregnant from the potential hazards of ionizing radiation).

Application of the principles of informed consent for patients undergoing examination or treatment.

Implementation of no-smoking and no-alcohol policies as appropriate.

Ensuring a safe working environment for patients and staff.

Correct disposal of needles and syringes.

Implementation of the Childrens Act (1989) in suspected cases of non-accidental injury (similar protection in the case of elderly and vulnerable patients).

job is solely concerned with the diagnosis or treatment of illness, and that health promotion is therefore, someone elses domain. If they do see a role for health promotion in their professional practice it is often confined to an authoritarian, expert-led exercise limited to imparting information, for example distributing leaflets exhorting individuals to adopt certain behaviours.

There was a diversity of opinion concerning which individuals or groups should be targeted for health promotion activities. This was reflected in the variety of views expressed during the plenary session. These views centred on the pragmatic approach highlighting scarce resources and limited time which favoured educating educators and targeting particular at-risk groups. The idealistic

14 Castle & Reeves

Table 3. Health education opportunities

Ensuring adequate knowledge of relevant health issues to help patients make informed choices (i.e.

empowerment).

Making presentations to groups (e.g. schoolchildren) about the nature of cancer treatment, and effects of ionizing radiation etc.

Application of ethical principles of/justice and respect for persons and their autonomy.

Developing assertion skills to aid effective, honest and clear communication between practitioner and patient.

Providing advice and counseiling as appropriate, and having an empathetic approach when dealing with patients.

Provision of posters and information leaflets in departments, and being available and able to answer patients questions.

Developing an undergraduate curriculum aimed at promoting health.

Being up-to-date in the theory and practice of radiography, and being aware of ethical issues and relevant research.

Encouraging both patients and staff to look after themselves (e.g. breast self-examination, foot and back care, personal hygiene).

Understand the concept of risk with regard to the use of ionizing radiations, and ensure appropriate examination or treatment is given.

Table 4. Evaluation questionnaire (n=39)

Statement YES! yes? not

no? NO! Total sure

I consider myself well informed about health promotion 11 16 8 4 39

I found this workshop worth attending 12 20 6 1 39

I did not understand some aspects of the workshop 2 14 7 7 9 39

I can see the relevance of health promotion 20 13 4 1 1 39 in my professional practice

I will find it difficult to implement health any promotion activity in my professional practice

2 7 8 9 13 39

I shall investigate further opportunities for health promotion in my professional practice

22 8 5 3 1 39

I enjoyed the in which the workshop was way presented 21 I1 5 1 1 39

approach advocated health education fof all on the basis that everyone has a right to optimum health.

tend to be targeted but, due to socio-economic

This led to a view that in practice at-risk groups realities, often do not respond to health promotion activities.

Health Promotion 15

Many participants saw a negotiated approach to health promotion as being the most effective. However, there was still plenty of discussion about the need for legislative back-up, as in the example of the United Kingdom law on the compulsory use of seat belts in cars. This law was widely accepted after a prolonged negotiated stage with the general public in an attempt to positively influence behaviour. In general, it was concluded that there is a need for a two-pronged carrot and stick approach to health promotion if real advances are to be made. There was the diversity of international experience and perspective, and participants from third world countries felt a negotiated approach is much less likely to be successful with limitations in communication and education. The view was that if changes needed to be made then the only effective way forward was to adopt an authoritarian approach. A limitation of this paradigm was that participants were required to indicate a prefer- ence for the direct or indirect style of promoting health, although in fact many felt both were needed.

Activity 2

As can be seen from Tables I to 3, the three domains of disease prevention, health protection and health education are not separate compart- ments, as many of their activities may be combined. For example, health education has a part to play in both disease prevention and health protection. This overlap is exemplified by the fact that issues of radiation protection appear in all three domains. This overlapping of domains, together with the traditional view of radiography as being exclu- sively concerned with the diagnosis or treatment of disease, led to participants being initially reluctant to engage in a discussion about the opportunities for health promotion in professional practice. It was acknowledged by the authors that there was always the possibility of participants concluding that radiographers had no role to play in health promotion. However small group discussion focused on specific practical applications, and participants reported a wealth of potential scope for developing health promotion activities. The possibility of investigating and implementing opportunities for health promotion in radiographic practice was positively indicated on the evaluation forms.

Activity 3

In common with all group activities, there was not a consensus in response to the evaluation questionnaire. A few participants said they would not be able to implement health promotion activity in their practice, and some did not understand some aspects of the workshop. One could speculate .on reasons for this but these comments were not followed-up after the workshop.

Conclusions

There are criticisms of health promotion activity based upon its perceived low-status, lack of clear objectives and difficulty in measuring successful outcomes. Health promotion may also be seen as authoritarian and giving out negative messages criticising peoples lifestyles. As an activity it may be viewed as only being commonsense, too difficult and someone elses responsibility.

Health promotion is about changing ethos, stra- tegic planning and engaging in good practice. This is reflected in a broader health agenda in hospitals which considers the implementation of quality issues and promoting holistic care. Obviously this approach involves cooperation between govem- ment, health authorities, hospitals, professional bodies and individuals. Policies are devised by government and local health authorities and are concerned with the socio-economic and environ- mental inequalities associated with health. Hospitals and professional bodies develop codes of conduct and local rules, but interpretation and implementation are undertaken by the individual.

The question is how do radiographers, as individual practitioners, develop and implement health promotion activities? Part of the answer, as shown in Tables 1-3, is that radiographers already are involved in good health promotion practice. The way to take this forward is to increase awareness and improve practice through evidence-based research. Some examples of research activities might include the following.

Disease prevention: Widening the possibilities to improve services and uptake of screening programmes and taking an active role in support groups and services. These are the kind of extra services that purchasers expect when looking at the quality and range of services provided by a particular hospital.

16

Health, protection: Reviewing current techniques and refining appropriate protocols and codes of practice. This involves keeping abreast of current innovations and developing critical evaluation MIS.

Health education: Using surveys to investigate the general publics knowledge of imaging and radio- therapy departments. This educational role can lead to improved information for clients, and is concerned with empowerment and allowing people to make informed choices.

Health is no longer considered to be the sole domain of the medical profession who are concerned with disease, but it is seen as a positive concept emphasizing social and personal resources, as well as physical capacities. As a profession we are involved in the business of health, and it is incumbent upon practitioners to participate in health promotion strategies. To judge what possibilities are available for health promotion in professional practice, and having the necessary skills to take advantage of such opportunities goes beyond simply responding to the demands of others.

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Health promotion in radiographic practice